Readiness Assessment
5= Very ready, I can do this!4= Ready, but I have some concerns about implementing it3= Somewhat ready2= I don’t think I want to do this now but maybe in the future1= Not ready
Grandparents:
Parents:
Siblings:
Birth History
Medical DiagnosisIndicate any medical diagnosis, past or current
GI History
Weight History
Allergies
Medications & Supplements
Relationship
Major stressors in the last year? Rate on a scale of 1-10 (10 being the most stressful)
Sleep
Energy
Please indicate your average level of energy throughout the day using the scale 1-10 (1 is the lowest and 10 is the highest)
Strength Training
Stretching
Formal Sports (basketball, tennis, etc.)
Other Activity
Do you have, or have you had within the past year, any of the following?
(Only females complete this section)
Gynecology and PAP History
Pregnancy History
(Only males complete this section)
It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.
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